What Medicare Covers And What It Doesn’t: The Basics

What exactly does Medicare cover, and what must enrollees pay for out of pocket? This is a common question — rest assured you’re not alone trying to figure it all out.

When an enrollee is covered by “traditional” or “original” Medicare, certain kinds of care are not covered at all: routine dental care, hearing aids and glasses, long-term care, and alternative therapies like acupuncture.

Some good news about traditional Medicare, however, is that more than ever, it’s focused on covering preventive care services — thanks in part to the Patient Protection and Affordable Care Act of 2010.

Most preventive services are covered by original Medicare with no copays or deductibles:

Abdominal aortic aneurysm screenings
Alcohol misuse counseling
Bone mass measurements
Cardiovascular screenings
Colon cancer screenings (colorectal)
Depression screenings
Diabetes screenings
Diabetes self-management training
EKG screenings
Flu shots
Glaucoma tests
Hepatitis B shots
HIV screenings
Mammograms
Medical nutrition therapy services
Pap tests and pelvic exams
Preventive Visits (two types — one when you’re new to Medicare and one each year after that)
Pneumococcal shots
Prostate cancer screenings
Smoking cessation

Here’s what original Medicare won’t cover, or strictly limits:

Routine dental care. There’s no coverage for basic dental health care such as checkups, cleanings, or fillings, and there is no coverage for dentures. Even if Medicare has paid for you to have a tooth pulled in preparation for a medical procedure, you will be responsible for the cost of your dentures should you need them.

Complementary and alternative therapies. These kinds of treatments include homeopathy, naturopathy, acupuncture, holistic therapies, midwifery, and herbal medicine. Most chiropractic care is not covered.

Most care received outside of the U.S.

Long-term care. Medicare does not cover indefinite, long-term care, nor assisted living nor adult daycare. It covers short-term recovery from an illness or injury, including care in a nursing facility. Medicare does pay for recovery in a skilled nursing facility (SNF) after a three-day hospital stay and will also cover home health care (note: this is not round-the-clock care). Hospice care is also covered.

Hearing aids or the exams for prescribing/fitting hearing aids.

Personal care or custodial care: such as help with bathing, toileting and dressing (unless homebound and receiving skilled care) and nursing home care (except in a skilled nursing facility if eligible).